Asuhan keperawatan ICU (format)

ASUHAN KEPERAWATAN DI RUANG ICU

I.         PENGKAJIAN

Tanggal masuk                 :

Tanggal pengkajian          :

A.       Identitas Pasien

Nama                        :

Umur                         :

Alamat                      :

No Register               :

Ruang                       :

Cara Pengkajian        : Anamnesa, pemeriksaan fisik, catatan rekam medis

Diagnosa Medis        :

Penanggung jawab    :

B.       Riwayat Kesehatan

1.        Keluhan utama

2.        Riwayat penyakit sekarang

      

3.        Riwayat penyakit dahulu

4.        Riwayat penyakit keluarga

II.      PENGKAJIAN PRIMER

Airway
Breathing
Circulation
Disability
Explosure

III.   PENGKAJIAN SEKUNDER

A.       Pemeriksaan fisik

1.        Keadaan Umum

2.        Tanda-tanda vital

Tanggal	TD	Nadi	RR	Suhu

3.        Kepala

Bentuk
mata
hidung
telinga
mulut
leher

4.        Dada

Inspeksi
Palpasi
Perkusi
Auskultasi

5.        Abdomen

Inspeksi
Auskultasi
Perkusi
Palpasi

6.        Ekstremitas

Ekstremitas Atas

Tanggal/ jam	Kanan			Kiri
	Kesemutan	Edema	Nyeri	Kesemutan	Edema	Nyeri

Gerak                               

Kekuatan Otot  :               

Ekstremitas Bawah

Tanggal/ jam	Kanan			Kiri
	Kesemutan	Edema	Nyeri	Kesemutan	Edema	Nyeri

                  Gerak                   

Kekuatan Otot :

  

7.        Sistem Integumen

Tanggal/jam	Warna kulit	Turgor	Mukosa bibir	Capillary refill	Kelainan

8.        Genetalia

9.        Sistem Persyarafam

a)    Fungsi serebral/Status Mental

Tanggal
Status mental ·         Tingkat kesadaran ·         GCS ·         Gaya bicara
Fungsi Intelektual ·         Orientasi waktu ·         Orientasi tempat ·         Orientasi orang
Daya pikir ·         Spontan, alamiah, masuk akal ·         Kesulitan berpikir ·         Halusinasi
Status emosional ·         Alamiah dan datar ·         Pemarah ·         Cemas ·         Apatis

10.    Eliminasi

11.    Tingkat ketergantungan

Bathing
Dressing
Toileting
Transfering
Continence
Feeding
Indeks KATZ

12.    Status Cairan

Tanggal	Intake	Output	Balance Cairan
	Parenteral : Minum : Makan : Total :	Urine : IWL : Feses : Muntah : Drainase : Total :

13.    Pemeriksaan Penunjang

1)        Laboratorium

Pemeriksaan	Nilai	Satuan
			Nilai	Nilai	Nilai
Hb	13 - 16	%
Ht	40 - 54	%
Eritrosit	45 - 65	jt/ mmk
Leukosit	4 - 11	ribu/ mmk
Trombosit	150 - 400	ribu/mmk
Creatinin	0.6 - 1.3	mg/ dL
Albumin	3.4 - 5	mg/ dL
Gula Sewaktu	80 - 120	mg/ dL
Ureum	15 - 39	mg/ dL
Na	136 - 145	mmol/ L
K	3.5 - 5.1	mmol/ L
Cl	98 - 107	mmol/ L
Cholesterol	50 - 200	mg/ dL
Trigliserid	30 - 150	mg/ dL
Waktu protrombin	10 - 15	dtk
PPT kontrol	12.8
Waktu tromboplastin	23.4 - 36.8	dtk
pH	7,35–3,45
pCO2	35 - 45	mmHg
pO2	83 - 103	mmHg
HCO3	18 - 23	Mmol/L
AADO2	<100
Laktat	0,4 - 2
Base Excess

14.    Pemeriksaan Penunjang

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13.Therapy

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ANALISA DATA

Nama   :                                                                                                                       No CM :

Usia     :                                                                                                                       Dianosa Medis :

TANGGAL	DATA FOKUS	ETIOLOGI	MASALAH	TTD

PRIORITAS DIAGNOSA KEPERAWATAN

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RENCANA ASUHAN KEPERAWATAN

Nama   :                                                                                                                       No CM :

Usia     :                                                                                                                       Diagnosa Medis :

No Dx.	DIAGNOSA KEPERAWATAN	TUJUAN DAN KRITERIA HASIL	INTERVENSI	TTD

IMPLEMENTASI KEPERAWATAN

TGL/JAM	NO. DX.	IMPLEMENTASI	RESPON	TTD

EVALUASI

Nama   :                                                                                                                       No CM :

Usia     :                                                                                                                       Diagnosa Medis :

TGL/JAM	NO DX	EVALUASI ( SOAP )	TTD